 Research Insights Unfinished Business: Medicaid and Delivery Innovation Summary Introduction: Medicaid And Health Care Some states are implementing exciting health delivery innovations Delivery Innovation in their Medicaid programs. Examples discussed in this issue brief The Affordable Care Act (ACA) of 2010i and other recently enacted include the New York State Medicaid program’s “care manage- federal laws have set the stage for innovations in the organization, ment for all” initiative; the development of a safety net accountable delivery, and financing of U.S. health care. The law established the care organization (ACO) for a Medicaid expansion population in Center for Medicare and Medicaid Innovation within the Centers Hennepin County, Minnesota; and a system of 14 nonprofit, com- for Medicare & Medicaid Services (CMS) for the express purpose of munity care networks developed to serve Medicaid and uninsured testing “innovative payment and service delivery models to reduce people throughout North Carolina. program expenditures … while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Federally qualified health centers (FQHC) and state Medicaid Children’s Health Insurance Program (CHIP) benefits”.1 programs, which both serve low-income children and adults, can be partners in implementing innovations related to primary care, in- Recently, delivery innovations at the federal level have largely focused cluding patient-centered medical homes (PCMH). Moreover, state on innovations such as accountable care organizations (ACOs) in and regional Primary Care Associations and the National Associa- Medicare, which provide health insurance coverage for Americans tion of Community Health Centers (NACHC) can help implement age 65 and over. At the same time, some state Medicaid programs are innovations in primary care and take them to scale. Accountability implementing delivery innovations that hold great promise. for entities such as ACOs and PCMHs can be improved through the National Committee for Quality Assurance’s (NCQA) accredi- Medicaid, the nation’s principal safety net health insurance pro- tation, certification, and recognition programs. gram, is a joint federal-state program that covers more people than any other public or private health care program in the country. In 2007, it covered nearly 60 million individuals, including 29 million children, 15 million adults (primarily working-poor parents), 6 million seniors, and 8.8 million persons with disabilities (including Genesis of this Brief: This policy brief is drawn, in part, from a panel discussion on the same topic held on Tuesday, February 5, 2013, at AcademyHealth’s National Health Policy Conference in Washington, D.C. Panelists were James Tallon, Jr., president of the United Hospital Fund of New York; Jennifer DeCubellis, area director, Hennepin County, Minnesota Human Services and Public Health Department; David Stevens, M.D., director, Quality Center, National Association of Community Health Centers; and Patricia Barrett, M.P.H., vice president, product development, National Com- mittee on Quality Assurance (NCQA). Bruce Siegel, M.D., M.P.H., president and CEO of the National Association of Public Hospitals and Health Systems, introduced and moderated the panel. 1 1 Unfinished Business: Medicaid and Delivery Innovation 4 million children).2 The number of Medicaid enrollees is expected Below, we present some examples of delivery innovations in Medic- to increase under the ACA. aid: care management for all in New York State;3 a safety net ACO for a Medicaid expansion population in Hennepin County, Minnesota;10 Medicaid serves highly diverse populations, including low-income and a system of 14 nonprofit, community care networks that serve mothers and children, people with developmental disabilities or seri- more than a million Medicaid and uninsured people throughout ous mental illness, young adults with spinal cord injuries, and seniors North Carolina.11 with Alzheimer’s disease or other dementias. The populations served by Medicaid are also racially and ethnically diverse. We also discuss the role of FQHCs, state/regional Primary Care Asso- ciations, and the NACHC in the efforts of the CMS Center for Medi- The ACA affirmed and altered four of Medicaid’s four long-standing care and Medicaid Innovation to transform primary care through the roles in U.S. health care:3 provision of medical homes for Medicaid enrollees and uninsured people.12 Finally, we outline NCQA’s accreditation, certification, and 1. Medicaid provides health insurance for low-income children recognition programs, which set standards for entities such as ACOs and adults. To reduce the number of low-income people without and PCMHs that can help improve such entities’ accountability.13 health insurance, the ACA expanded eligibility for Medicaid to all U.S. citizens and legal immigrants under age 65 with incomes up Medicaid Redesign In New York State to 138 percent of the federal poverty level.ii Assuming full partici- The New York State Medicaid program, with a budget of over $50 pation in the Medicaid expansion by all states, the CMS Office of billion annually, is currently the largest Medicaid program in the the Actuary estimated that the expansion would bring 20 million United States, covering 5.1 million low-income state residents, people into Medicaid.4 The U.S. Supreme Court ruled in June including 1.9 million children, 2.0 million adults under age 65 and 2012 that the ACA’s Medicaid expansion was optional for states.5 without disabilities, and 1.2 million elderly or disabled beneficiaries.3 As of late February 2013, 24 states and the District of Columbia indicated that they would definitely participate in the Medicaid Upon taking office in 2011, New York Governor Andrew Cuomo cre- expansion, and 13 had indicated that they would not participate.6 ated a Medicaid Redesign Team, with 27 stakeholders from virtually 2. Medicaid provides comprehensive coverage to disabled, chronically, every sector of the health care system, to propose changes that would and complexly ill beneficiaries without access to other insurance, constrain costs and improve health outcomes.3 New York’s Medicaid including Medicare. Section 2703 of the ACA gives states the option program spends twice the national average on a per recipient basis of creating “health homes” to coordinate physical health, behavioral and faces some significant quality issues.14 health, and long-term care services for Medicaid beneficiaries with serious, persistent mental illness and/or specified combinations of “It is of compelling public importance that the state serious, high-cost, chronic conditions.7 conduct a fundamental restructuring of its Medicaid program to achieve measurable improvement in 3. Medicaid supplements Medicare coverage for elderly and disabled health outcomes, sustainable cost control and a individuals who need long-term care services and supports. With more efficient administrative structure.” the creation of CMS’s Federal Coordinated Health Care Office (Medicare-Medicaid coordination office), the ACA places a new – Governor Andrew M. Cuomo emphasis on coordinating care more efficiently for low-income, January 5, 2011 elderly, and disabled individuals who are dually eligible for Medi- In Phase 1, New York’s Medicaid Redesign Team developed a care and Medicaid.8 blueprint for lowering by $2.2 billion the state’s Medicaid spend- 4. Medicaid, beyond reimbursing for services, provides various types ing in state fiscal year 2011–2112 without cuts to eligibility.15 The of financial support for safety net providers, including hospitals, legislature approved nearly all of the recommendations in the plan, community health centers, and faith-based and mission-driven which reflected extensive feedback from citizens and stakeholders. organizations. The ACA expands health insurance coverage for The recommendations are now undergoing implementation.14 To previously uninsured people served by safety net providers and bring greater fiscal discipline and transparency into state Medicaid gives FQHCsiii incentives and opportunities to promote the coor- program spending, New York adopted the key recommendation, dination and integration of care for the patients they serve. which called for imposing a global spending cap on the state’s share of Medicaid spending. 5. At the same time, however, the ACA mandates cuts in Medicaid disproportionate share funding to safety net and other hospitals that serve large numbers of uninsured people beginning in 2014.9 2 Unfinished Business: Medicaid and Delivery Innovation In Phase 2, the Medicaid Redesign Team broke into 10 workgroups, • Developmental Disabilities Individual Support and Care which included additional citizens and stakeholders, to address Coordination Organizations (DISCO). The New York State more complex issues and oversee the process of implementing Office for People with Developmental Disabilities is developing a the team’s recommendations. The result was a five-year plan for a new Section 1115 Medicaid waiver (People First Waiver) to serve thorough overhaul of New York’s Medicaid program. Under the people with developmental disabilities through specialized care plan, the state began work in 2012 to ensure that virtually all Med- coordination entities.20 icaid enrollees are in care management by April 2016.16 Over time, Hennepin Health: A Safety Net Aco For A Medicaid the goal is to integrate fully the management of individuals’ acute, Expansion Population In Minnesota long-term, and behavioral health care.17 New York is also redirect- Minnesota is one of the states that is pioneering efforts to develop ing almost all Medicaid spending from a fee-for-service basis to safety net ACOs to serve Medicaid patients.21 Hennepin Health in care management, under which an intermediary is paid a capitated Hennepin County, Minnesota—a provider-sponsored entity that rate and is responsible for managing patient care and reimbursing is accountable for improving the health and care experience of a service providers. defined Medicaid population and is 100 percent at risk for financial outcomes—is the country’s first safety net ACO. Embracing the “Triple Aim” of improving the patient’s care experience (including quality and satisfaction), improving the health of popula- Hennepin Health launched in 2012 as a two-year Medicaid dem- tions, and reducing, or at least controlling, the per capita cost of care,14 onstration to provide care for up to 10,000 of the poorest Medicaid New York State is staking its Medicaid redesign on a major program patients—namely, childless adults age 21 to 64 with incomes at innovation. The key elements of innovation include the following:3 or below 75 percent of the poverty level ($677 per month for one • Mainstream Medicaid managed care plans. Most Medicaid person). The idea behind Hennepin Health is that significant health recipients in New York who are not enrolled in Medicare are now outcomes for the target population cannot be achieved without ad- either enrolled in “mainstream” Medicaid managed care plans or dressing the social determinants of health, including food, housing, will be required to enroll soon. transportation, and finding and retaining a job.10 • PCMH. To ensure that all Medicaid enrollees have access to high- By coordinating systems and services, Hennepin Health must pro- quality primary care, New York plans to expand access to PCMHs vide the basic Medicaid benefit, but it may also provide other physi- to all Medicaid recipients over the next several years.3 cal, mental, dental, and social support services to bring down overall • Health homes. New York’s Medicaid program views the health costs. Minnesota pays a per member per month fee to Hennepin home option for people with severe, persistent mental illness and/ Health, which is the same amount that insurance companies receive or specified chronic conditions in Section 2703 of the ACA as an for treating childless adults with incomes under 75 percent of the essential part of its strategy of care management for all.17 One poverty level. The four partners participating in Hennepin Health challenge is to coordinate with health homes the care delivered by (Hennepin County Medical Center, NorthPoint Health & Wellness, different types of providers to Medicaid enrollees. Hennepin County’s Human Services and Public Health Depart- ment, and Metropolitan Health Plan) share and reinvest profits • Behavioral health organizations. New York’s Medicaid program from the venture and are 100 percent at risk in the case of losses.22 is committed to improving the care management of people with mental health and/or substance use disorders through behavioral Hennepin Health’s goals for years 1 and 2 were to improve its en- health organizations. It hopes eventually to integrate and coordinate rollees’ health outcomes and reduce overall costs; decrease hospital behavioral health care delivery with physical health care delivery.17 admissions/readmissions by more than 10 percent; reduce emer- • Managed long-term care. New York has made a major commit- gency department visits by more than 10 percent; increase primary ment to providing managed long-term care to help people in need care “touches” by more than 5 percent; and reduce churn (maintain health and long-term care services remain in their homes and coverage by more than 95 percent).10 Recognizing that 5 percent of communities as long as possible.18 its enrollees were using 64 percent of funds, Hennepin Health has worked to integrate care coordination for its high-cost and high- • Fully Integrated Duals Advantage Program. To improve the need beneficiaries. Hennepin Health has also focused on responding coordination and integration of care provided to people who are to individuals with high behavioral health needs who were “stuck” dually eligible for Medicare and Medicaid and tend to be older in hospital beds; helping individuals failing transitions between than the average Medicaid recipient, New York plans to move programs; ensuring that individuals were not misusing crisis care such people in 2014 into its Fully Integrated Duals Advantage venues; and reducing system fragmentation and duplication. Program, established under a Medicaid waiver.19 3 Unfinished Business: Medicaid and Delivery Innovation Figure 1: Map of Areas Served by Community Care of North Carolina’s (CCNC) Community Networks Alleghany Warren Northhampton Gates r Ashe Surry Stokes Rockingham Caswell Person a Hertford Watauga Halifax Chowan Wilkes Yadkin Granville Alamance Forsyth Bertie Guilford Orange Franklin Durham Caldwell Alexander Davie Nash Tyrrell Madison Edgecombe Wake Washington Dare Iredell Davidson Martin Burke Wilson Randolph Chatham Buncombe McDowell Catawba Rowan Haywood Pitt Beaufort Swain Hyde Lincoln Johnston Rutherford Lee Greene Graham Henderson Cabarrus Harnett Jackson Gaston Stanly Wayne Polk Cleveland Montgomery Moore Lenoir Cherokee Mecklenburg Craven Macon Clay Pamlico Cumberland Sampson Jones Richmond Hoke Union Anson Duplin Scotland Onslow Robeson Bladen Pender Hanover Columbus Brunswick Legend AccessCare Network Sites Community Care Plan of Eastern Carolina AccessCare Network Counties Community Health Partners Community Care of Western North Carolina Northern Piedmont Community Care Community Care of the Lower Cape Fear Northwest Community Care Carolina Collaborative Community Care Partnership for Community Care Community Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont Carolina Community Health Partnership Source: CCNC March 2013 The results from the Hennepin Health Medicaid ACO demonstra- start later in the year. In February 2013, CMS awarded Minnesota tion project are extremely encouraging, and both patients and a State Innovations Model Initiative grant to test and implement a providers are enthusiastic about the outcomes.10 Hospital admis- statewide accountable care model. The initiative will create linkages sions and emergency room use have dropped significantly while among Medicaid ACOs, Medicare, and commercial insurers to primary care has increased. Moreover, 87 percent of served patients promote care coordination and access to a wide range of acute care, report that they are “likely to recommend” Hennepin Health.10 behavioral care, long-term care, public health, and social services. The outcomes point to a huge opportunity in “managing” care for the Medicaid expansion population in order to alter the cost curve Roles Of FQHCs, Primary Care Associations, And while improving patient satisfaction. NACHC In Medicaid In Delivery Innovation FQHCs are the largest network of safety net primary care providers Moreover, with health plans and providers operating on a level in the nation.12 FQHCs and Medicaid are likely partners in delivery playing field in Hennepin Health, all entities are motivated to innovation. Their missions are aligned, and they both serve low- work together to achieve shared outcomes, including improved income populations, face the need for strong and effective primary health and cost savings. What makes the Hennepin Health ACO care supported by payment reforms and a quality improvement model sustainable are the flexibility of funding from Minnesota’s infrastructure, and must account for and affect the social and be- leaders to bridge funding gaps and the reinvestment of savings havioral health aspects of health.11 into enhancements for Hennepin Health, leading to cost reduc- tions of at least 30 percent.10 Under the ACA, FQHCs are the nucleus for many of the nation’s efforts to eliminate disparities in health and health care by expand- Medicaid officials in Minnesota believe that, unlike other enti- ing access to high-value primary care in underserved populations. ties, ACOs are better able to integrate services across settings.23 Six Moreover, they are poised to play an essential role in implementing other Medicaid ACOs became operational in Minnesota in January the provisions of the law that are intended to reinvent the deliv- 2013, and three more are negotiating with Minnesota Medicaid to ery of primary care.12 Below, we highlight a few examples of how FQHCs, state and regional Primary Care Associations (private, 4 Unfinished Business: Medicaid and Delivery Innovation nonprofit membership organizations of FQHCs and safety net ing under a fixed budget that grows at a fixed rate, is accountable providers), and the NACHC can help implement innovations in for coordinating and integrating the physical, mental/substance primary care and take them to scale. abuse, and dental health care of the Oregon Health Plan patients it serves.27 The objective is to cut health cost by 2 percentage points North Carolina: FQHCs as Partners in Innovation in Primary and improve health outcomes. Care Infrastructure North Carolina provides a medical home and care management The arrangements for payments to Oregon’s CCOs have not in- to more than a million Medicaid enrollees and uninsured people cluded any risk adjustment for social determinants of health such as through a nonprofit organization known as Community Care of homelessness, joblessness, and lack of social support. In response, North Carolina (CCNC). CCNC has established an innovative the Oregon legislature passed Senate Bill 1522 in 2012 that requires model of care built around 14 nonprofit, community networks the Oregon Health Authority to account for the psychological and made up of physicians, hospitals, social service agencies, and county social factors facing members of coordinated care organization health departments that provide and manage care for residents when establishing quality measures and global budgets.28 throughout the state (Figure 1). All of North Carolina’s FQHCs are members of the CCNC community networks, and some FQHCs Working with a group of pilot FQHCs, the Oregon Primary Care lead CCNC networks.11 Association is identifying, through its electronic health record, the social and individual barriers to health and health care as well as the CCNC’s community networks are responsible for managing their enabling services, such as language services, outreach, home visits, enrollees’ care, including linking enrollees to a medical home, and coordination, needed to address these barriers. The aim is to providing disease and case management services, and implement- document resource requirements for future payment models. ing quality improvement initiatives.24 North Carolina identifies priorities for statewide disease and care management initiatives and Missouri: State Primary Care Association’s Role in Capacity provides supplemental funding to the networks for care manage- Building and Alignment ment and quality improvement initiatives.25 Primary care provid- Missouri operates two separate health home programs for Medicaid ers in the network receive a payment on a per member per month beneficiaries with chronic conditions, each of which received CMS basis, and each network receives an additional per member per approval under a separate state plan amendment: month payment ($2.50 and $5 for elderly and disabled enrollees, • The first is a Primary Care Health Home initiative for Medic- respectively) for care management. aid beneficiaries with at least $2,600 in annual health costs who qualify for enrollment by virtue of at least two chronic condi- CCNC is in the top 10 percent of HEDIS (Healthcare Effectiveness tions—including asthma, diabetes, cardiovascular disease, obesity, Data and Information Set) measures for health plans for diabe- tobacco use, and developmental disability—or one chronic tes, asthma, and heart disease. Moreover, the 2007 to 2010 health condition and risk for another. care utilization patterns and trends of the populations enrolled in CCNC are consistent with high-performing medical homes. A re- • The second is a Community Mental Health Center (CMHC) cent analysis by the actuarial firm Milliman, Inc., estimated savings Health Home Initiative for Medicaid beneficiaries with serious achieved by CCNC from 2007 through 2010 at nearly $1 billion.25 mental health conditions. The operation of two health home programs proved to be a chal- Other payers and major employers are interested in the benefits of lenge because of overlapping providers—FQHCs, CMHCs, and CCNC’s approach, which has been adopted successfully in both public entity primary care clinics—serving Medicaid beneficiaries urban and rural areas and has reduced costs while improving qual- who might qualify for both programs.11 ity of care. With the support of the Commonwealth Fund, CCNC has launched a new Web site dedicated to helping others learn from To address that challenge, several partners—including MO its experience.26 HealthNet (Missouri Medicaid), the Missouri Department of Oregon: State Primary Care Association’s Role in Mental Health, Missouri Foundation for Health, Missouri Pri- Health Innovation mary Care Association, and Missouri Coalition of Community Oregon, along with Minnesota, Utah, and Colorado, is in the fore- Mental Health Centers—worked together to coordinate the two front of efforts to develop safety net ACOs for Medicaid popula- state initiatives through learning collaboratives and individual- tions.21 In September 2012, with nearly $2 billion in federal funds, ized practice coaching for health home providers in the state. The Oregon launched a five-year Medicaid ACO demonstration involv- Missouri Foundation for Health funded the learning collabora- ing 15 coordinated care organizations (CCO). Each CCC, operat- tives and coaching. The partnership has helped health home 5 Unfinished Business: Medicaid and Delivery Innovation providers gain PCMH recognition from NCQA as well as CMHC More recently, NCQA has developed a recognition program for accreditation from the Commission on Accreditation of Rehabili- specialty practices interested in becoming part of a PCMH “neigh- tation Facilities. It also illustrates the role of a state Primary Care borhood”.13 NCQA hopes that the program, which began in March Association in capacity building and as a system integrator in col- 2013, will help improve communication and coordination among laboration with state partners. specialty practices that work with PCMHs to coordinate care, pro- vide timely access to services, use information technology to reduce National Partnership: Role of NACHC in Harnessing State In- test duplication, and work toward continuous quality improvement. novation PCMH Initiatives About 1,200 FQHCs across the country serve 20 million patients, in- Challenges Ahead cluding low-income individuals and families, migrant and seasonal Any consideration about innovation should focus on the following farm workers, individuals without health insurance, and people three questions:3 who are homeless or living in public housing. Nearly 500 FQHCs are now participating in the CMS FQHC Advanced Primary Care • Innovation. What is different? Practice Demonstration to evaluate the effect of the PCMH on the • Scale. Once an innovation has been piloted and validated at the care provided to Medicare beneficiaries served by FQHCs, including local level, can it be scaled up and replicated elsewhere? Medicare beneficiaries also covered by Medicaid.29 • System change. How can several innovations (information State Primary Care Associations, the American Institutes for technology, patient engagement, patient reform, and so forth) be Research, MacColl Center for Healthcare Innovation, National Asso- channeled to lead to system change? ciation of Community Health Centers’ (NACHC) Patient-Centered Innovations in Medicaid can potentially affect health care Medical Home Institute (which includes Primary Care Associa- throughout the country. Unlike the case of Medicare, however, tions), and Qualis Health have all joined forces to help the FHQCs the states administer Medicaid. Thus, one of the challenges for the participating in the CMS demonstration achieve the highest level of CMS Center for Medicare and Medicaid Innovation and others PCMH recognition (Level 3) from NCQA. A system of state-based is to ensure that islands of successful Medicaid innovations at practice facilitators, Webinars addressing NCQA recognition and the local or state level are taken to scale in the states and adopted practice transformation, monthly “office hours” for participating broadly across the country.31 sites, and monthly forums for practice coaches all offer support for practice transformation to PCMH. Another challenge is to channel several innovations to achieve the “Triple Aim” of improving the patient experience of care, improving NCQA’s Standards Related To Medicaid the health of populations, and reducing the cost of health care for Delivery Innovation individuals, families, employers, and government by reducing or at NCQA offers a range of health care accreditation, certification, and least controlling the per capita cost of care. recognition programs to improve accountability at all levels in the U.S. health care system: health plans, insurers, ACOs and other orga- About the Author nized delivery systems, and medical practices.13 Kerry B. Kemp is an independent health policy analyst and writer in Washington, D.C. In 2008, NCQA launched a recognition program with standards for PCMHs.30 The program requires participants to satisfy ele- About AcademyHealth ments in nine standard categories, and NCQA offers various levels AcademyHealth is a leading national organization serving the fields of PCMH recognition (Level 1, 2, or 3) depending on whether the of health services and policy research and the professionals who various elements are in place. Thirty-three states have launched produce and use this important work. Together with our members, public and private PCMH initiatives that use NCQA recognition. we offer programs and services that support the development and Moreover, as noted, FQHCs participating in the CMS Center for use of rigorous, relevant, and timely evidence to increase the quality, Medicare & Medicaid Innovation’s FQHC Advanced Primary Care accessibility, and value of health care, to reduce disparities, and to Practice Demonstration must have Level 3 PCMH designation improve health. A trusted broker of information, AcademyHealth from NCQA.29 brings stakeholders together to address the current and future needs of an evolving health system, inform health policy, and translate evidence into action. For additional publications and resources, visit www.academyhealth.org. 6 Unfinished Business: Medicaid and Delivery Innovation Endnotes 13. Barrett P. Medicaid and delivery innovation: view from NCQA. Presentation at session “Unfinished Business: Medicaid and Delivery Innovation” at i. The Affordable Care Act (ACA) of 2010 refers to two separate pieces of AcademyHealth’s National Health Policy Conference, Washington, DC, Feb legislation—the Patient Protection and Affordable Care Act (Public Law 111- 4-5, 2013. Available from: http://www.academyhealth.org/files/nhpc/2013/ 148) and the Health Care and Education Reconciliation Act of 2010 (Public Patricia%20Barrett.pdf. Law 111-152)—that, together, expand Medicaid coverage and make numerous changes to Medicaid and the Children’s Health Insurance Program (CHIP). 14. Helgerson JA, Medicaid Director, New York State Department of Health. Testimony for Senate Aging Committee Hearing, Washington, DC, 2012 Jul ii. The ACA expands Medicaid eligibility to U.S. citizens and legal immigrants 18. Available from: http://www.aging.senate.gov/events/hr249jh.pdf. below 133 percent of the federal poverty level, but, with no mandatory income disregard in the ACA equal to 5 percent of the federal poverty level, the 15. New York State Department of Health. Redesigning New York’s Medicaid effective income limit is 138 percent of the federal poverty level. program. 2013; Available from: http://www.health.ny.gov/health_care/ medicaid/redesign/. iii. FQHCs are federally funded, nonprofit, community-based health centers or clinics that serve medically underserved areas and populations. They provide 16. New York State Department of Health. Care management for all. 2012. comprehensive primary care and preventive care to residents of all ages Available from: http://www.health.ny.gov/health_care/medicaid/redesign/ regardless of their ability to pay and charge for services on a sliding-fee scale docs/care_manage_for_all.pdf. based on the patient’s ability to pay. 17. New York State Department of Health. A plan to transform the Empire State’s 1. Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid program: multi-year action plan. 2012. Available from: http://www. Medicaid Services, U.S. Department of Health and Human Services. “About health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf. the CMS Innovation Center.” 2012; Available from: http://innovation.cms.gov/ 18. New York State Department of Health. Managed long-term care. 2013 Jan; about/index.html. Available from: http://www.health.ny.gov/health_care/managed_care/mltc/. 2. Kaiser Commission on Medicaid and the Uninsured. The Medicaid program 19. Samis S, Detty A, Birnbaum M. Integrating and improving care for dual at a a glance. 2010 Jun. Available from: http://www.kff.org/medicaid/ Medicare-Medicaid enrollees: New York’s proposed Fully Integrated Duals upload/7235-04.pdf. Advantage (FIDA) Program. 2012. Available from: http://www.uhfnyc.org/ 3. Tallon J. Medicaid and delivery innovation: a national view and a New publications/880865. York snapshot. Presentation at session “Unfinished Business: Medicaid and 20. New York State Office for People with Developmental Disabilities. People Delivery Innovation” at AcademyHealth’s National Health Policy Conference, first waiver home. 2013; Available from: http://www.opwdd.ny.gov/opwdd_ Washington, DC, Feb 4-5, 2013. Available from: http://www.academyhealth. services_supports/people_first_waiver/home. org/files/nhpc/2013/Jim Tallon - Feb 5 - AcademyHealth.pdf. 21. Gold M, Nysenbaum J, Streeter S. Emerging Medicaid accountable care 4. Mathematica Policy Research. Who will enroll in Medicaid in 2014? Lessons organizations: the role of managed care. Kaiser Commmission on Medicaid from Section 1115 Medicaid waivers. Medicaid Policy Brief [Internet]. and the Uninsured [Internet]. 2012 May. Available from: http://www.kff.org/ 2011 May. Available from: http://www.cms.gov/Research-Statistics-Data- medicaid/upload/8319.pdf. and-Systems/Computer-Data-and-Systems/MedicaidDataSourcesGenInfo/ downloads/MAX_IB_1_080111.pdf. 22. Lowen T. On the path to ACOs: providers and payers test new care delivery and payment models. Minnesota Medicine [Internet]. 2012. Available from: 5. Henry J. Kaiser Family Foundation. A guide to the Supreme Court’s decision http://www.minnesotamedicine.com/PastIssues/November2012/ACOs.aspx. on the ACA’s Medicaid expansion. 2012 Aug. Available from: http://www.kff. org/healthreform/upload/8347.pdf. 23. Edwards JN. Health care payment and delivery reform in Minnesota Medicaid. Aligning incentives in Medicaid [Internet]. 2013 Mar. Available from: http:// 6. Advisory Board. Where each state stands on ACA’s Medicaid expansion. 2012 www.commonwealthfund.org/~/media/Files/Publications/Case Study/2013/ Feb [updated 2013 Feb. 20]; Available from: http://www.advisory.com/Daily- Mar/1667_Edwards_Medicaid_Minnesota_case_study_FINAL_v2.pdf. Briefing/2012/11/09/MedicaidMap. 24. Kaiser Commission on Medicaid and the Uninsured. Community care of 7. Centers for Medicare and Medicaid Services, U.S. Department of Health and North Carolina: putting health reform ideas into practice in Medicaid. 2009. Human Services. Health homes. n.d. [2013 Feb]; Available from: http://www. Available from: http://www.kff.org/medicaid/upload/7899.pdf. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term- Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html. 25. Community Care of North Carolina. Community care of North Carolina: 2012 overview. 2012. Available from: https://http://www.communitycarenc.org/our- 8. Centers for Medicare and Medicaid Services. About the Medicare-Medicaid results/. coordination office. n.d. [cited 2013 Feb]; Available from: http://www.cms.gov/ Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/ 26. Community Care of North Carolina. The CCN toolkit: CCNC’s “how to” Medicare-Medicaid-Coordination-Office/index.html. guide. 2013; Available from: https://http://www.communitycarenc.org/ population-management/care-management/toolkit/. 9. Riley P, Berenson J, Demody C. How the Affordable Care Act supports a high-performance safety net. The Commonwealth Fund Blog [Internet]. 2012 27. Oregon Health Policy Board. Coordinated care organizations. 2013; Available Jan 16. Available from: http://www.commonwealthfund.org/Blog/2012/Jan/ from: http://www.oregon.gov/OHA/OHPB/pages/health-reform/ccos.aspx. Affordable-Care-Act-Safety-Net.aspx. 28. 76th Oregon Legislative Assembly. Senate bill (SB) 1522. 2012. Available from: 10. DeCubellis J. Hennepin Health. Presentation at session “Unfinished Business: http://www.leg.state.or.us/12reg/measpdf/sb1500.dir/sb1522.intro.pdf. Medicaid and Delivery Innovation” at AcademyHealth’s National Health Policy Conference, Washington, DC, Feb 4-5, 2013. 29. Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. FQHC 11. Stevens D. National Association of Community Health Centers (NACHC). advanced primary care practice demonstration. n.d. [2013 Feb]; Available Presentation at session “Unfinished Business: Medicaid and Delivery from: http://innovation.cms.gov/initiatives/FQHCs/. Innovation” at AcademyHealth’s National Health Policy Conference, Washington, DC, Feb 4-5, 2013. 30. National Committee for Quality Assurance. NCQA’s patient-centered medical home (PCMH) 2011 [Internet]. Washington, DC2011; Available from: http:// 12. National Association of Community Health Centers. Community health www.ncqa.org/tabid/631/default.aspx. centers lead the primary care revolution. Capital Link [Internet]. 2010 Aug. Available from: http://www.nachc.com/client/documents/Primary_Care_ 31. Siegel B. Introduction. Presentation at session “Unfinished Business: Medicaid Revolution_Final_8_16.pdf. and Delivery Innovation” at AcademyHealth’s National Health Policy Conference, Washington, DC, Feb 4-5, 2013. 7